N.S. van den Berg

An innovative multimodality approach for sentinel node mapping and biopsy in head and neck malignancies

PURPOSE Recent innovations such as preoperative SPECT/CT, intraoperative imaging using portable devices and a hybrid tracer were evaluated in a multimodality approach for sentinel node (SN) mapping and biopsy in head and neck malignancies. MATERIAL AND METHODS The evaluation included 25 consecutive patients with head and neck malignancies (16 melanomas and 9 oral cavity squamous cell carcinomas). Patients were peritumorally injected with the hybrid tracer ICG-(99m)Tc-nanocolloid. SNs were initially identified with lymphoscintigraphy followed by single photon emission computed tomography (SPECT/CT) 2 hours after tracer administration. During surgery a portable gamma camera in combination with a near-infrared fluorescence camera was used in addition to a handheld gamma ray detection probe to locate the SNs. RESULTS In all patients the use of conventional lymphoscintigraphy, SPECT/CT and the additional help of the portable gamma camera in one case were able to depict a total of 67 SNs (55 of them visualized on planar images, 11 additional on SPECT/CT and 1 additional with the portable gamma camera). A total of 67 of the preoperatively defined SNs together with 22 additional SNs were removed intraoperatively; 12 out of the 22 additional SNs found during operation were located in the vicinity of the injection site in anatomical areas such as the periauricular or submental regions. The other 10 additional SNs were found by radioguided post-resection control of the excision SN site. CONCLUSION In the present series 26% additional SNs were found using the multimodal approach, that incorporates SPECT/CT and intraoperative imaging to the conventional procedure. This approach appears to be useful in malignancies located close to the area of lymphatic drainage such as the periauricular area and the oral cavity.

Valor añadido del trazador híbrido verde de indocianina-99mTc-nanocoloide para la biopsia del ganglio centinela en una serie de pacientes con drenaje en diferentes territorios anatómicos

INTRODUCTION Indocyanine green (ICG)-(99m)Tc-nanocolloid is a novel hybrid fluorescent radioactive tracer for sentinel node (SN) biopsy. This study has aimed to evaluate the added value of this novel versatile tracer in a series of patients with different malignancies. MATERIAL AND METHODS Twenty patients (with penile carcinoma, oral cavity tumors, melanoma) were consecutively included between March-May 2012. Planar lymphoscintigraphy was performed 15 min and 2h after injection of ICG-(99m)Tc-nanocolloid followed by SPECT/CT. Blue dye (1 ml) was injected in 14 patients in surgery room. Intraoperatively, SNs were localized using a gamma probe and visualized by optical SN-detection using blue dye and fluorescence imaging. Finally, a portable gamma camera was used to confirm complete SN removal. RESULTS At least one SN was identified by SPECT/CT in all patients. All SNs (total 68, 100%) were excised using a combination of radio- and fluorescence guidance: 89.7% were intraoperatively localized with the gamma probe. The remaining SNs, located near the injection site, were localized using fluorescence imaging. During the surgery, 97% of the SNs were fluorescent while only 39.2% were stained blue. Ex vivo, all SNs were both radioactive and fluorescent. The SN was positive in 5 patients. CONCLUSION Synchronous radio- and fluorescence guided SN biopsy is feasible using ICG-(99m)Tc-nanocolloid. This hybrid approach combines the beneficial properties of both modalities. Adding fluorescence imaging improves optical SN detection compared to blue dye. It has been shown to be especially useful in the localization of SNs near the injection site.

Utilidad de la SPECT-TC para la localización anatómica de los ganglios centinelas presacrales y pararrectales en el cáncer de próstata

AIM This study has aimed to evaluate the added value of SPECT-CT scan in the preoperative assessment of sentinel nodes of the presacral and pararectal regions localized outside the standard area of extended pelvic lymphadenectomy for the staging of the pelvis in prostate cancer. SPECT-CT scan can serve as a guide for the excision of these nodes by lymphadenectomy by open surgery or laparoscopy. MATERIAL AND METHODS We evaluated 4 patients with prostate cancer presenting sentinel nodes in the pararectal and presacral regions on SPECT-CT scan performed in addition to lymphoscintigraphy. These patients underwent lymphadenectomy with robot-assisted laparoscopy together with prostatectomy. All of the excised lymph nodes were sent for histopathology study. RESULTS An average of 6 sentinel nodes per patient were found on SPECT-CT scan with a mean of 2 sentinel nodes in presacral/pararectal región. Lymphadenectomy including these areas was performed. Pararectal/presacral sentinel nodes of all patients depicted by SPECT-CT scan were tumor free on histopathology study. Sentinel nodes (no pararectal/presacral) were positive for malignancy in only one patient. CONCLUSION Preoperative SPECT-CT scan is a useful tool to localize the sentinel nodes in pararectal/presacral regions. It can be an anatomic guide for new modalities of laparoscopic surgery such as robot-assisted procedures that can access the pelvic areas visualized with SPECT-CT scan, making excision of these nodes possible.

4 Robotgeassisteerde laparoscopische prostatectomie met een schildwachtklierprocedure op geleide van fluorescentie en radioactiviteit

Tijdschrift voor Urologie mei 2013 nr. 3 klierdissectiepreparaten als gouden standaard gold. 3. Er werd een internationale, multicentrische cohortstudie uitgevoerd met 211 patiënten die een CTen FDG-PET-CT-scan ondergingen ter stadiëring van MIBC. We modelleerden de associatie tussen de aanwezigheid van extravesicale PET-positieve laesies verdacht voor maligniteit op PET-CT en de mortaliteit.

1 Augmented reality gebaseerde navigatie voor robotgeassisteerde laparoscopische prostatectomie en schildwachtklierbiopsie bij patiënten met prostaatkanker

Introductie Onlangs is de hybride tracer ICG-99mTc-nanocolloïd geïntroduceerd voor detectie van schildwachtklieren (SWK’s). De tracer is zowel fluorescent als radioactief. Hierdoor is het mogelijk om preoperatieve beeldvorming en intraoperatieve visualisatie van de SWK’s te bewerkstelligen. Door een beperkte penetratie van het fluorescente signaal is het lastig om SWK’s met fluorescentie alleen te lokaliseren. Navigatiesystemen maken het mogelijk intraoperatief het radioactieve signaal te lokaliseren met Freehand SPECT (FHS), waarna er een 3D-weergave van dit signaal wordt gemaakt en toegevoegd aan het reële beeld (AR = augmented reality). Deze pilotstudie beschrijft het gebruik van FHS voor SWK-navigatie bij prostaatkanker.